May 2008

Volume 247, Issue 2

Next Article
Original Research
Cardiac Imaging
Dual-Source CT: Effect of Heart Rate, Heart Rate Variability,
and Calcification on Image Quality and Diagnostic Accuracy
Harald Brodoefel, MD, Christof Burgstahler, MD, Ilias Tsiflikas, MD, Anja
Reimann, MD, Stephen Schroeder, MD, Claus D. Claussen, MD, Martin
Heuschmid, MD, and Andreas F. Kopp, MD
1
From the Departments of Diagnostic Radiology (H.B., I.T., A.R., C.D.C., M.H., A.F.K.) and
Cardiology (C.B., S.S.), Eberhard-Karls-University, Hoppe-Seyler-Str 3, 72076 Tübingen,
Germany. Received May 24, 2007; revision requested July 31; revision received September
9; accepted October 9; final version accepted October 29.

Address correspondence to H.B. (e-mail: h.brodoefel@t-online.de)

DOI: http://dx.doi.org/10.1148/radiol.2472070906

 Abstract

 Full Text

 Figures

 References

 Cited by

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In the field of noninvasive coronary artery imaging, motion and blooming artifacts have been
recognized as the essential challenges to image quality and accurate detection of vessel stenosis
(1,2). While cardiac motion is mainly a concern at elevated or irregular heartbeat, blooming artifacts
are caused by severe calcification which may, at its worst, lead to obscuration of the entire vessel
lumen.

In the past few years, advances in spatial and temporal resolution translated into better image quality
and improved accuracy for the detection of high-grade stenosis (3–12). Thereby, 16- and 64-section
computed tomographic (CT) technology had the potential to extend acceptable image quality to higher
heart rates and likewise reduce blooming artifacts related to heavy calcification (13–16). However,
even with 64-section CT, with its superior gantry rotation speed of 330 msec and isotropic spatial
resolution of 0.4 mm3, elevated and irregular heartbeats were found to cause relevant degradation of
image quality (16–20). Moreover, severe calcification has persistently been linked to a decrease in
diagnostic accuracy (12,21).

Recently, a CT system equipped with two tubes and corresponding detectors in a 90° geometry has
been designed and provides temporal resolution of approximately a quarter of its 330-msec gantry
rotation time (22). This approach thus allows a temporal resolution of 83 msec, which is independent
of the patient's heart rate and eliminates the need for dual-segment reconstruction algorithms. Results
of pilot studies on cardiac applications of this dual-source CT system have been promising, and
results of a feasibility study have shown excellent accuracy for detection of coronary artery disease in
an unselected patient cohort (23–25). However, to date, effects of heart rate and heart rate variability
on diagnostic accuracy have not been systematically assessed in a larger patient cohort to our
knowledge.

The aim of our study was to prospectively evaluate the effect of heart rate, heart rate variability, and
calcification on dual-source CT image quality and to prospectively assess the diagnostic accuracy of
dual-source CT for coronary artery stenosis, by using invasive coronary angiography as the reference
standard.

MATERIALS AND METHODS

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Study Patients

Our study protocol was approved by the local Ethics Committee, with radiation dose information
having been supplied to that Committee. All patients provided informed consent for participation in the
study after having been informed of radiation dose information.
From September 2006 to March 2007 we screened 119 patients who were scheduled to undergo
invasive coronary angiography because they were suspected of having coronary artery disease or
because progression of known coronary artery disease was suspected. Exclusion criteria were renal
insufficiency (serum creatinine level > 1.5 mg/dL [132.6 μmol/L]), hyperthyroidism (basal thyroid-
stimulating hormone < 0.03 μL/L), known allergic reaction to iodinated contrast medium, and inability
to follow breath-hold commands. Patients who underwent bypass surgery were excluded from this
study, while patients with coronary artery stent grafts were not. Eight patients could not be enrolled
because of refusal or withdrawal of consent. Two patients were excluded because of impaired renal
function, seven were excluded because of previous bypass surgery, and one was excluded because
of acute coronary syndrome necessitating immediate invasive coronary angiography. After coronary
CT angiography, one patient declined to undergo invasive coronary angiography. Thus, the ultimate
study population comprised 100 patients (20 women, 80 men; mean age, 62 years ± 10). Seventy-five
of these patients were taking a beta-blocker as part of their baseline medication. Additional beta-
blocker medication was not administered. All dual-source CT studies were performed the day prior to
invasive coronary angiography.

Coronary CT Angiography

CT studies were performed with a dual-source scanner (Somatom Definition; Siemens Medical
Solutions, Forchheim, Germany) in all patients and were performed without complications. Prior to
acquisition of the topogram, patients received a single dose of 2.5 mg of isosorbiddinitrate (Isoket;
Schwarz Pharma, Monheim, Germany).

Total calcium burden was assessed by using an initial unenhanced CT scan with the following
parameters: collimation, 32 × 0.6 mm; section acquisition, 64 × 0.6 mm with the z-flying focal spot
technique; gantry rotation time, 330 msec; pitch, 0.2–0.39, depending on heart rate; tube current, 80
mAs per rotation; and tube voltage, 120 kV.

For contrast material–enhanced studies, vessel opacification was achieved by using automated
injection (CT2; Medtron, Saarbrücken, Germany) of 80 mL of iomeprol (Imeron 400; Altana, Konstanz,
Germany) at a flow rate of 5 mL/sec and a 60-mL chaser bolus. Estimation of individual circulation
time was based on the test-bolus technique, by using a 20-mL bolus and dynamic evaluation software
(Dyn Eva; Siemens).

For coronary CT angiography, collimation was 32 × 0.6 mm; section acquisition was 64 × 0.6 mm with
the z-flying focal spot technique; gantry rotation time was 330 msec; pitch was 0.20–0.43, adapted to
heart rate; tube voltage was 120 kV; and maximum tube current was 400 mAs per rotation. For dose
reduction, prospective tube current modulation was applied. Thereby, at heart rates less than 60 beats
per minute, full tube current was applied from 60% to 70% of the cardiac cycle; at heart rates 60–70
beats per minute, from 50% to 80% of the cardiac cycle; and at heart rates higher than 70 beats per
minute, from 30% to 80% of the cardiac cycle.

For data reconstruction, a single-segment reconstruction algorithm was applied, which used the data
of a quarter rotation of both detectors for image reconstruction.

For calcium scoring, the standard reconstruction window was set at 60% of the R-R interval by using
nonoverlapping images with 3-mm effective section thickness and a medium-sharp convolution kernel
(B35f).

For CT angiography, an initial reconstruction window was based on the results of a test series that
were obtained in a transverse plane at the level of segment 2 and that displayed reconstruction
window offsets by 5% of the entire cardiac cycle. In case of motion artifacts in the initial
reconstruction, further reconstructions were performed in 5% increments of the cardiac cycle until all
individual arteries could be visualized at optimal image quality.

In case of arrhythmia, R-wave indicators were manually adapted to improve the quality of
synchronization.

Effective section thickness was 0.75 mm, with a reconstruction increment of 0.4 mm. Data sets were
filtered with a medium-soft convolution kernel (B26f).

Image Analysis

CT data were referred to an offline workstation (Leonardo; Siemens) and were interactively assessed
by two readers (H.B. and A.R., each with 4 years of experience in cardiovascular radiology) who were
blinded to the results of invasive coronary angiography and to clinical information. Decisions were
reached with consensus reading.

The Agatston score was assessed on unenhanced images with a detection threshold of 130 HU by
using semiautomated software (Syngo Calcium Scoring; Siemens).

Contrast-enhanced dual-source CT was evaluated by using thin-slab maximum intensity projection,

along with curved-planar reformation and three-dimensional volume rendering.

For the rating of image quality and stenosis detection, a modified model of the coronary tree with 13
segments was employed (26): For the right coronary artery, segment 1 was considered proximal; 2,
middle; 3, distal; and 4, combined posterior descending and posterolateral branches. Segment 5 was
considered the left main stem artery. For the left anterior descending artery, 6 was considered
proximal; 7, middle; 8, distal; 9, first diagonal; and 10, second diagonal. For the left circumflex artery,
11 was considered proximal; 12, marginal branches; and 13, combined distal American Heart
Association segments 13, 14, and 15.

Image quality was classified for each segment as being excellent (absence of artifacts related to
motion or coronary calcification), as indicated with a score of 1; good (minor artifacts), score of 2;
moderate (considerable artifacts but maintained visualization of arterial lumen), score of 3; or poor
(nondiagnostic because of severe motion artifacts or extensive wall calcification), score of 4.

Segments were visually scored for the presence of significant stenosis (≥50% narrowing in luminal
diameter). In the case of multiple lesions per segment, the segment was classified by using the worst
stenosis.

Invasive Coronary Angiography

Conventional coronary angiography was performed by two experienced cardiologists (C.B. and S.S.,
with 7 and 13 years of experience, respectively) according to standard procedures by using the
transfemoral or transradial Judkins technique. To visualize the right coronary artery, at least two
projections were obtained; for the left coronary artery, at least six projections were obtained. Stenosis
severity was evaluated by using quantitative coronary analysis (QCA, version 3.3; Philips, Eindhoven,
the Netherlands).

All invasive coronary angiograms were evaluated by a single observer (C.B.) who was blinded to CT
results. Segmental disease was analyzed in each vessel by using the same 13-segment model
employed for dual-source CT analysis. Lesions with a stenosis 50% or more in diameter were
considered to be significant. Stenosis severity was classified on the projection with maximal luminal
diameter stenosis.

Statistical Analysis

Statistical analysis was performed with software (JMP, version 6, SAS Institute, Cary, NC; GraphPad
Prism, version 4.00, GraphPad Software, San Diego, Calif; Stata, version 9.2, StataCorp, College
Station, Tex). A P value of less than .05 indicated a statistically significant difference.

Quantitative variables were expressed as means ± standard deviations; categoric variables were
expressed as frequencies or percentages. Values of image quality are given in means ± standard
deviations. Impact of heart rate, heart rate variability, or calcification on mean image quality per
patient was tested by using multivariate linear regression analysis and effect testing. Thereby, heart
rate was defined as mean heart rate during examination; heart rate variability refers to the maximal
spread of heart rate during examination. Calcification is quantified by Agatston score. Interaction
between variables was checked by including multiplicative terms in the initial model; colinearity of x
variables was ruled out by calculating the variance inflation factor. In case of skewed distribution,
logarithmic transformation of x variables was performed (log 10). Simple linear regression was
performed to plot effects of the above parameters against image quality, and thresholds were
calculated by using a linear regression equation.

Image quality and the number of nondiagnostic segments in subgroups of the predictor variables were
compared by using Mann-Whitney or Kruskal-Wallis statistics with Dunn multiple-comparison test.

The diagnostic performance of dual-source CT for the detection of significant stenosis is presented as
sensitivity, specificity, positive predictive value, negative predictive value, and accuracy. Comparison
between dual-source CT and coronary angiography was performed on a per-segment and per-patient
basis (presence or absence of at least one significant coronary artery stenosis).

The impact of heart rate, heart rate variability, or calcification on the accuracy for all segments was
tested by using multivariate logistic regression analysis. The per-segment accuracy across subgroups
of predictor variables was compared by using univariate logistic regression. For both tests, we took
into account the clustered nature of the data by using a generalized estimating equation population-
averaged model.

Retrospective power calculations were performed for nonsignificant results in between-subgroup

comparisons for image quality and diagnostic accuracy. For image quality, power was calculated as a
function of a .05 significance level, the given data structure (sample size and standard deviation), and
a clinically meaningful effect size. For accuracy, power was calculated by simulation analyses with
1000 replications according to the observed intrapatient correlation, the distribution between
subgroups, and clinically meaningful effect sizes.

RESULTS
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Study Patients

Evaluation of both image quality and diagnostic accuracy was based on a total of 1229 segments
among 100 patients (Table 1, Fig 1). Sixty-six segments were excluded from analysis because of
stent-graft placement; five segments were nonaccessible because of variations in coronary anatomy
(n = 3) or small vessel diameter (n = 2). Agatston score was 400 or less in 53 patients and more than
400 in 47 patients. Median calcium score was 370 (mean score, 787).

Image Quality
Mean image quality for all included segments was 2.1 ± 0.6. In detail, image quality was excellent in
267 (21.7%), good in 615 (50.0%), and moderate in 227 (18.5%) segments. Poor or nondiagnostic
image quality was found in 120 (9.8%) segments. Thereby, severe calcification degraded image
quality in 100 (8.1%) segments; 20 (1.6%) segments were rendered nondiagnostic because of
abundant motion artifacts (Figs 2–5).

According to multivariate regression analysis, heart rate variability and calcium score were the only
variables with significant impact on image quality of all segments (P = .015 and P < .001,
respectively). The effect of heart rate was not significant (P = .14).

The significant effect of calcification was confirmed for all arteries, while the effect of heart rate
variability proved true for all vessels except the left main artery. Heart rate independence of image
quality was likewise established for the entire vessel tree.

Heart Rate and Image Quality

Mean image quality and the total number of motion-degraded segments were not significantly different
in patients with heart rates more than 70 beats per minute compared with patients with heart rates 70
or fewer beats per minute (P = .13 and .37, respectively) (Table 2). Given the sample size of 100
patients and the observed standard deviations in our subgroups for image quality, this analysis had
94% power to detect a difference between the means of image quality of 0.50.

According to linear regression analysis of mean image quality for all coronary segments against heart
rate and the use of a linear regression equation, good or excellent image quality can be achieved for
heart rates up to 95.2 beats per minute (Fig 6).

Heart Rate Variability and Image Quality

In line with results from multivariate regression analysis, differences between subgroups were
considerable (P = .002) (Table 3). By contrast, the number of motion-degraded segments was not
significantly different between the subgroups of heart rate inconsistency (P = .11).

Linear regression analysis of mean image quality of all segments against heart rate variability reveals
a cutoff for good image quality at 29.9 beats per examination (Fig 7).

Calcium Score and Image Quality

Image quality was significantly degraded in the presence of Agatston scores higher than 400 (P < .01)
(Table 4). No difference was found between scores 100 or lower and scores greater than 100 but less
or equal to 400 (P > .05). At the same time, the number of nondiagnostic segments was significantly
higher in subgroups of elevated calcium score (P < .001).
Linear regression analysis of mean segmental image quality against calcium score suggests that
good image quality is obtainable for Agatston scores up to 375.8 (Fig 8).

Accuracy of Lesion Detection

In our collective, overall accuracy on the basis of a per-segment analysis was 91.9% (1129 of 1229).
Overall sensitivity was 91.1% (236 of 259), specificity was 92.0% (893 of 970), positive predictive
value was 75.4% (236 of 313), and negative predictive value was 97.5% (893 of 916). On the basis of
a per-patient analysis, accuracy was 95.0% (95 of 100), sensitivity was 100% (73 of 73), specificity
was 81.5% (22 of 27), positive predictive value was 93.6% (73 of 78), and negative predictive value
was 100% (22 of 22).

Diagnostic Accuracy and Heart Rate, Heart Rate Variability, or Calcification

According to a multivariate logistic regression analysis considering the effect of heart rate, heart rate
variability, and calcium score on the accuracy of lesion detection, calcification was the single factor
with a significant influence (P = .002). At the same time, there was a significant difference between
accuracies among the three subgroups of Agatston score (Table 4) (P < .001).

According to multivariate regression analysis, heart rate and heart rate variability showed no impact
on accuracy of lesion detection (P = .95 and .56, respectively). Accuracies were equal among
subgroups of these predictor variables (Tables 2, 3) (P = .73 for heart rate, P = .09 for heart rate
variability). Given the observed data structure, the analyses had 85% power to detect absolute
differences in accuracy by subgroups of heart rate and heart rate variability of 8% each.

DISCUSSION
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Our primary study findings are threefold: First, in a patient population that is unselected for heart rate,
arrhythmias during the examination, and calcification, dual-source CT resulted in good image quality
and high diagnostic accuracy, both of which were independent of patient heart rate. Second, while
inconsistency of heartbeat during examination does exert a considerable effect on image quality, there
is no translation of such effect into deterioration of diagnostic accuracy. Finally, excessive calcification
was found to pose a serious limitation to image quality and was linked to a significant reduction in
diagnostic accuracy.
The overall accuracy that was found for dual-source CT in our patient group is comparable to
previously reported data on the use of 64-section scanners (9,10,12). Nevertheless, in contrast to
these studies, our data were obtained in an unselected patient group with excessive Agatston scores
and without an additional beta-blocker premedication for heart rate control or minimization of
intercycle variability.

The benefit of improved temporal resolution with dual-source CT is evident from results of multivariate
regression analysis, which showed heart rate to have no effect on image quality and diagnostic
accuracy. This finding was true on a segmental and arterial basis and was confirmed with an
additional investigation of two subgroups for heart rate.

According to linear regression analysis performed for heart rate against image quality, dual-source CT
results in good image quality at heart rates up to 95.2 beats per minute.

Interestingly, with regard to 64-section CT systems, a conceivable effect of heart rate on diagnostic
accuracy has been controversially discussed. While Raff et al (12) found a significant degradation of
accuracy in subgroups of elevated heart rate, such inverse correlation was less obvious according to
results of other investigations (7–9,11). By contrast, almost all studies on 64-section CT revealed a
persistent significant impact of heart rate on image quality (16,17,19,20).

Our data suggest a superior stability of dual-source CT in the setting of elevated heart rate. The
finding of heart-rate independent image quality may represent another milestone in cardiac CT.

Interexamination heart rate variability results in unpredictability of R-R intervals and subsequent
impairment of electrocardiographically gated image-reconstruction technique. Interestingly, results of
a recent study (16) on 64-section CT showed heart rate variability as a major determinant of image
quality while, in the same collective, heart rate itself was ruled out as a significant predictor variable.

Likewise, in our investigation on dual-source CT, heart rate variability was proved to have significant
effect on image quality of all included segments or individual coronary arteries. Of note, in our
unselected patient collective, mean interexamination variability was excessive and considerably
exceeded changeability findings in the above cited analysis on 64-section CT (16). Indeed, according
to our linear regression analysis, dual-source CT may result in good image quality until a variability of
29.9 beats per examination.

It is of special interest that effects of heart rate changeability on image quality did not translate into a
loss of diagnostic accuracy. The most likely explanation is that deterioration of global image quality
was predominantly caused by a shift of excellent toward good or good toward moderate image quality;
the number of motion-degraded, nondiagnostic segments proved equal in both subgroups of heart
rate variability. This preservation of diagnostic image quality reflects the improved temporal resolution
of dual-source CT. As with 64-section CT, arrhythmia still necessitates a thorough manual
repositioning of R-wave indicators in case of inadequate automatic synchronization. Yet, enhanced
stability in the setting of irregular heartbeat represents a major advantage over previous CT
generations and may eventually extend the application of noninvasive coronary angiography to
patients known to have arrhythmia.

According to our multivariate regression analysis, vessel calcification was a serious challenge to
accurate assessment of coronary arteries. Given a median Agatston score of 370 (mean, 787), overall
calcium burden in our study was comparatively high and, indeed, effects on image quality and
diagnostic accuracy were highly significant. A total of 100 (8.1%) segments that were considered
nondiagnostic because of abundant calcification suggest that calcium burden remains a fundamental
problem of coronary CT angiography and is certainly not addressed by exclusive increase of temporal
resolution. In fact, according to linear regression analysis, there is a persistent threshold for adequate
image quality at an Agatston score around 400. This finding is in agreement with previous data (12)
on 64-section CT, which likewise show a significant loss of accuracy in a subgroup for patients with a
calcium score more than 400.

Our study had limitations. As all patients were referred to our center for catheterization, there was a
considerable patient selection bias with a prevalence of coronary artery disease of 73%. At the same
time, our study excluded patients with acute coronary syndromes, and further investigations are
needed to determine diagnostic accuracy in such patients.

The study design has a lack of direct comparison with previous CT generations; hence, the benefit of
increased temporal resolution may not be quantified, and differences in results may potentially be
attributed to different population variables. The evaluation of coronary artery stenosis was performed
with consensus reading instead of independent reading, and quantification was performed by using
visual assessment.

Because the primary focus of our study was on image quality and accuracy as functions of multiple
predictors, the outcome variable was kept as homogeneous as possible and stents were excluded
from the analysis.

In conclusion, we demonstrated that improved temporal resolution with dual-source CT provides

heart-rate independent image quality within a wide range of patient heart rates. While
interexamination variability has a persistent impact on global image quality, there is a large cutoff for
good image quality and no translation of effect into deterioration of accuracy. Such findings have
important implications for the administration of beta-blockers or exclusion of patients with arrhythmia
and may eventually broaden the clinical indications for coronary CT angiography. With further
increase of temporal resolution, calcification emerges as the primary cause of degraded image quality
and continues to pose a fundamental challenge to diagnostic accuracy.
ADVANCES IN KNOWLEDGE
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•.
Results of multifactor logistic regression analysis show that dual-source CT results in
good image quality that is independent of heart rate.

•.
Despite a persistent inverse correlation of image quality to heart rate variability with
dual-source CT, there is no translation of such effect into deterioration of accuracy.

•.
With dual-source CT, calcification emerges as the primary cause of degraded image
quality and continues to pose a fundamental challenge to diagnostic accuracy.

IMPLICATION FOR PATIENT CARE

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•.
Our findings have potential implications on administration of beta-blockers or
exclusion of patients with arrhythmia and may eventually broaden the clinical
indications for coronary CT angiography.

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Figure 1: Chart of patient flow and outcome for CT angiography (CTA) and the reference standard,
invasive coronary angiography (ICA). Abnormal result and target are defined as significant coronary
artery stenosis per segment or per patient. ACS = acute coronary syndrome.
Open in Image Viewer

Figure 2a: CT angiographic images show good image quality despite mean heart rate of 98 beats per
minute. On curved-planar reconstructions, the (a) right coronary artery, (b) left anterior descending
artery, and (c) circumflex artery are displayed in their entire length without motion artifacts.

Open in Image Viewer

Figure 2b: CT angiographic images show good image quality despite mean heart rate of 98 beats per
minute. On curved-planar reconstructions, the (a) right coronary artery, (b) left anterior descending
artery, and (c) circumflex artery are displayed in their entire length without motion artifacts.

Open in Image Viewer

Figure 2c: CT angiographic images show good image quality despite mean heart rate of 98 beats per
minute. On curved-planar reconstructions, the (a) right coronary artery, (b) left anterior descending
artery, and (c) circumflex artery are displayed in their entire length without motion artifacts.

Open in Image Viewer

Figure 3a: (a) Curved-planar CT reconstruction and (b) conventional CT angiogram of left anterior
descending artery in a 72-year-old patient with Agatston score of 379, heart rate of 61 beats per
minute, and heart rate variability of 45 beats per examination. Dual-source CT imaging resulted in
moderate image quality, and soft-plaque stenosis in segment 7 (arrow in a) is suspected.
Angiographic results confirm high-grade stenosis in mid left anterior descending artery (arrow in b). At
the same time, significant stenosis was ruled out for mixed plaque in segment 6, which suggests
difficulty with coronary calcification.

Open in Image Viewer

Figure 3b: (a) Curved-planar CT reconstruction and (b) conventional CT angiogram of left anterior
descending artery in a 72-year-old patient with Agatston score of 379, heart rate of 61 beats per
minute, and heart rate variability of 45 beats per examination. Dual-source CT imaging resulted in
moderate image quality, and soft-plaque stenosis in segment 7 (arrow in a) is suspected.
Angiographic results confirm high-grade stenosis in mid left anterior descending artery (arrow in b). At
the same time, significant stenosis was ruled out for mixed plaque in segment 6, which suggests
difficulty with coronary calcification.

Open in Image Viewer

Figure 4a: (a) Maximum intensity CT projection, (b) curved-planar CT reconstruction,

and (c)conventional angiogram of right coronary artery in a 58-year-old patient with Agatston score of
417, heart rate of 88 beats per minute, and heart rate variability of 26 beats per examination. Dual-
source CT imaging resulted in good image quality despite elevated heart rate and considerable
variability of heartbeat. High-grade stenosis (arrow) in segment 2 is confirmed at angiography.

Open in Image Viewer

Figure 4b: (a) Maximum intensity CT projection, (b) curved-planar CT reconstruction,
and (c)conventional angiogram of right coronary artery in a 58-year-old patient with Agatston score of
417, heart rate of 88 beats per minute, and heart rate variability of 26 beats per examination. Dual-
source CT imaging resulted in good image quality despite elevated heart rate and considerable
variability of heartbeat. High-grade stenosis (arrow) in segment 2 is confirmed at angiography.

Open in Image Viewer

Figure 4c: (a) Maximum intensity CT projection, (b) curved-planar CT reconstruction,

and (c)conventional angiogram of right coronary artery in a 58-year-old patient with Agatston score of
417, heart rate of 88 beats per minute, and heart rate variability of 26 beats per examination. Dual-
source CT imaging resulted in good image quality despite elevated heart rate and considerable
variability of heartbeat. High-grade stenosis (arrow) in segment 2 is confirmed at angiography.

Open in Image Viewer

Figure 5a: Images of false-positive finding in a 65-year-old patient with Agatston score of 510, heart
rate of 68 beats per minute, and heart rate variability of 39 beats per examination. (a) Maximum
intensity CT projection and (b) curved-planar CT reconstruction show poor image quality in segment 7
due to extensive calcification and motion artifacts (arrow); (c) assumption of high-grade stenosis was
not confirmed at angiography.

Open in Image Viewer

Figure 5b: Images of false-positive finding in a 65-year-old patient with Agatston score of 510, heart
rate of 68 beats per minute, and heart rate variability of 39 beats per examination. (a) Maximum
intensity CT projection and (b) curved-planar CT reconstruction show poor image quality in segment 7
due to extensive calcification and motion artifacts (arrow); (c) assumption of high-grade stenosis was
not confirmed at angiography.

Open in Image Viewer

Figure 5c: Images of false-positive finding in a 65-year-old patient with Agatston score of 510, heart
rate of 68 beats per minute, and heart rate variability of 39 beats per examination. (a) Maximum
intensity CT projection and (b) curved-planar CT reconstruction show poor image quality in segment 7
due to extensive calcification and motion artifacts (arrow); (c) assumption of high-grade stenosis was
not confirmed at angiography.

Open in Image Viewer

Figure 6: Linear regression plot of mean image quality of all coronary segments (excluding segments
nondiagnostic because of calcification) against mean heart rate during CT examination. Slope is not
significantly different from zero (P = .12). Dashed lines = 95% confidence limits. According to linear
correlation, the x-intercept is 95.2 beats per minute when y is 2.0.

Open in Image Viewer

Figure 7: Linear regression plot of mean image quality of all coronary segments (excluding segments
nondiagnostic because of calcification) against the logarithm of heart rate variability during CT
examination. On the x-axis, corresponding raw values of logarithms are denoted in parentheses.
Slope is significantly different from zero (P = .004). Dashed lines = 95% confidence limits. According
to linear correlation, the x-intercept is 29.9 beats per examination when y is 2.0.

Open in Image Viewer

Figure 8: Linear regression plot of mean image quality of all coronary segments against Agatston
score. Slope is significantly different from zero (P < .001). Dashed lines = 95% confidence limits.
According to linear correlation, x-intercept is at Agatston score of 375.8 when y is 2.0. Ca = calcium.

Open in Image Viewer

Table 1. Patient Characteristics

Table 1.Patient Characteristics

Click image to enlarge

Note.—Unless otherwise indicated, data are numbers of patients.

*
 Values are means ± standard deviations.

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Table 2. Diagnostic Accuracy according to Heart Rate

Table 2.Diagnostic Accuracy according to Heart Rate

Click image to enlarge

Note.—Data in parentheses are numbers used to calculate percentages.

*
 Values are means ± standard deviations.

†
 Segments are nondiagnostic because of motion.

View larger version

 Table 3. Diagnostic Accuracy according to Heart Rate
Variability

Table 3.Diagnostic Accuracy according to Heart Rate Variability

Click image to enlarge

Note.—Data in parentheses are numbers used to calculate percentages.

*
 Values are means ± standard deviations.

†
 Segments are nondiagnostic because of motion.

View larger version

Table 4. Diagnostic Accuracy according to Calcification

Table 4.Diagnostic Accuracy according to Calcification

Click image to enlarge

Note.—Data in parentheses are numbers used to calculate percentages.

*
 Values are means ± standard deviations.

†
 Segments are nondiagnostic because of calcium.

View larger version

Author contributions: Guarantors of integrity of entire study, H.B., C.B., A.F.K.; study concepts/study
design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or
manuscript revision for important intellectual content, all authors; manuscript final version approval, all
authors; literature research, H.B., A.F.K.; clinical studies, C.B., I.T., A.R., M.H.; statistical analysis,
H.B.; and manuscript editing, H.B., C.B., S.S., C.D.C., M.H., A.F.K.

Authors stated no financial relationship to disclose.

The authors thank Jacqueline Buros from the PERFUSE Core Laboratory and Data Coordinating
Center at Harvard Medical School for her substantial contribution to the statistical analysis of our data.

References
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1. Rumberger JA. Noninvasive coronary angiography using computed tomography: ready to kick it up
another notch? Circulation2002; 106: 2036–2038. CrossRef, Medline

2. Schoepf UJ, Becker CR, Ohnesorge BM, Yucel EK. CT of coronary artery
disease. Radiology 2004; 232: 18–37. Link

3. Ehara M, Surmely JF, Kawai M, et al. Diagnostic accuracy of 64-slice computed tomography for
detecting angiographically significant coronary artery stenosis in an unselected consecutive patient
population: comparison with conventional invasive angiography. Circ J 2006; 70: 564–
571. CrossRef, Medline

4. Herzog C, Zwerner PL, Doll JR, et al. Significant coronary artery stenosis: comparison on per-
patient and per-vessel or per-segment basis at 64-section CT angiography. Radiology 2007;
244: 112–120. Link

5. Hoffmann MH, Shi H, Manzke R, et al. Noninvasive coronary angiography with 16-detector row CT:
effect of heart rate.Radiology 2005; 234: 86–97. Link

6. Kuettner A, Trabold T, Schroeder S, et al. Noninvasive detection of coronary lesions using 16-
detector multislice spiral computed tomography technology: initial clinical results. J Am Coll
Cardiol 2004; 44: 1230–1237. CrossRef, Medline

7. Leber AW, Knez A, von Ziegler F, et al. Quantification of obstructive and nonobstructive coronary
lesions by 64-slice computed tomography: a comparative study with quantitative coronary
 angiography and intravascular ultrasound. J Am Coll Cardiol 2005; 46: 147–
154. CrossRef, Medline

8. Leschka S, Alkadhi H, Plass A, et al. Accuracy of MSCT coronary angiography with 64-slice
technology: first experience. Eur Heart J 2005; 26: 1482–1487. CrossRef, Medline

9. Mollet NR, Cademartiri F, van Mieghem CA, et al. High-resolution spiral computed tomography
coronary angiography in patients referred for diagnostic conventional coronary
angiography. Circulation 2005; 112: 2318–2323. CrossRef, Medline

10. Nikolaou K, Knez A, Rist C, et al. Accuracy of 64-MDCT in the diagnosis of ischemic heart
disease. AJR Am J Roentgenol2006; 187: 111–117. CrossRef, Medline

11. Pugliese F, Mollet NR, Runza G, et al. Diagnostic accuracy of non-invasive 64-slice CT coronary
angiography in patients with stable angina pectoris. Eur Radiol 2006; 16: 575–
582. CrossRef, Medline

12. Raff GL, Gallagher MJ, O'Neill WW, Goldstein JA. Diagnostic accuracy of noninvasive coronary
angiography using 64-slice spiral computed tomography. J Am Coll Cardiol 2005; 46: 552–
557. CrossRef, Medline

13. Brodoefel H, Reimann A, Heuschmid M, et al. Non-invasive coronary angiography with 16-slice
spiral computed tomography: image quality in patients with high heart rates. Eur Radiol 2006;
16: 1434–1441. CrossRef, Medline

14. Cademartiri F, Mollet NR, Lemos PA, et al. Impact of coronary calcium score on diagnostic
accuracy for the detection of significant coronary stenosis with multislice computed tomography
angiography. Am J Cardiol 2005; 95: 1225–1227. CrossRef,Medline

15. Herzog C, Nguyen SA, Savino G, et al. Does two-segment image reconstruction at 64-section CT
coronary angiography improve image quality and diagnostic accuracy? Radiology 2007; 244: 121–
129.

16. Leschka S, Wildermuth S, Boehm T, et al. Noninvasive coronary angiography with 64-section CT:
effect of average heart rate and heart rate variability on image quality. Radiology 2006; 241: 378–
385. Link

17. Ferencik M, Nomura CH, Maurovich-Horvat P, et al. Quantitative parameters of image quality in
64-slice computed tomography angiography of the coronary arteries. Eur J Radiol 2006; 57: 373–
379. CrossRef, Medline

18. Herzog C, Arning-Erb M, Zangos S, et al. Multi-detector row CT coronary angiography: influence of
 reconstruction technique and heart rate on image quality. Radiology 2006; 238: 75–86. Link

19. Leschka S, Husmann L, Desbiolles LM, et al. Optimal image reconstruction intervals for non-
invasive coronary angiography with 64-slice CT. Eur Radiol 2006; 16: 1964–
1972. CrossRef, Medline

20. Wintersperger BJ, Nikolaou K, von Ziegler F, et al. Image quality, motion artifacts, and
reconstruction timing of 64-slice coronary computed tomography angiography with 0.33-second
rotation speed. Invest Radiol 2006; 41: 436–442. CrossRef, Medline

21. Ong TK, Chin SP, Liew CK, et al. Accuracy of 64-row multidetector computed tomography in
detecting coronary artery disease in 134 symptomatic patients: influence of calcification. Am Heart
J 2006; 151: 1323.e1–e6. CrossRef, Medline

22. Flohr TG, McCollough CH, Bruder H, et al. First performance evaluation of a dual-source CT
(DSCT) system. Eur Radiol 2006; 16: 256–268. CrossRef, Medline

23. Achenbach S, Ropers D, Kuettner A, et al. Contrast-enhanced coronary artery visualization by

dual-source computed tomography: initial experience. Eur J Radiol 2006; 57: 331–
335. CrossRef, Medline

24. Johnson TR, Nikolaou K, Wintersperger BJ, et al. Dual-source CT cardiac imaging: initial
experience. Eur Radiol 2006; 16:1409–1415. CrossRef, Medline

25. Scheffel H, Alkadhi H, Plass A, et al. Accuracy of dual-source CT coronary angiography: first
experience in a high pre-test probability population without heart rate control. Eur Radiol 2006;
16: 2739–2747. CrossRef, Medline

26. Bashore TM, Bates ER, Berger PB, et al. American College of Cardiology/Society for Cardiac
Angiography and Interventions Clinical Expert Consensus Document on cardiac catheterization
laboratory standards: a report of the American College of Cardiology Task Force on Clinical Expert
Consensus Documents. J Am Coll Cardiol 2001; 37: 2170–2214. CrossRef, Medline